I am a plastic surgeon in Little Rock, AR. I used to "suture for a living", I continue "to live to sew". These days most of my sewing is piecing quilts. I love the patterns and interplay of the fabric color. I would like to explore writing about medical/surgical topics as well as sewing/quilting topics. I will do my best to make sure both are represented accurately as I share with both colleagues and the general public.

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Monday, January 21, 2008

Orbital fractures are challenging injuries. They frequently are a component of a more global facial injury. With this post, I'm going to try to concentrate on the orbital fracture, not the broader picture.

In 1957, Smith and Regan (in one article--5th reference) and Smith and Converse (6th reference) coined the term "blow-out fracture" when describing inferior rectus entrapment with decreased ocular motility in the setting of an orbital floor fracture. Pure orbital floor fractures are also referred to as isolated floor fractures.

ANATOMY

Seven bones make up the orbit: the frontal bone, maxilla, zygoma, ethmoid, lacrimal bone, greater and lesser wings of the sphenoid, and palatine bone.The orbital process of the frontal bone and the lesser wing of the sphenoid form the orbital roof. The orbital plate of the maxilla joins the orbital plate of the zygoma and the orbital plate of the palatine bones to form thefloor. The medial wall of the orbit consists of the frontal process of the maxilla, the lacrimal bone, the sphenoid, and the thin lamina papyracea of the ethmoid. The lateral wall is formed by the lesser and greater wings of the sphenoid and the zygoma.

The major nerves and vessels to the orbit and globe enter through 3 openings: 1)the superior orbital fissure, 2) the infraorbital fissure, and 3) the optic canal. These three "fissures" create weak points.

For a complete discussion of the anatomy of the orbit, including the vessels, nerves, and ocular muscles, go to this eMedicine article: Orbit Anatomy by Guy J Petruzzelli MD (December 15, 2005).

The article by Manson (9th reference) gives an excellent description of the anatomy of the ligamentous support of the globe. Lockwood's suspensory ligament is a fascial hammock that extends from the medial to the lateral wall of the orbit, cradling the eyeball and helping maintain the vertical level of the globe. When intact, it can support the globe even when the bony orbital floor may be compromised.

MECHANISM OF INJURY

Fractures of the orbit usually result from an impact injury to the globe and upper eyelid. The object is usually large enough not to perforate the globe and small enough not to result in fracture of the orbital rim. Examples include a fist, tennis ball, baseball, snowball or door knob. These fractures are more common in males, between the ages of 21 to 30 years.

The mechanism of a blow out fracture is controversial. There are two main theories that are likely: 1) The fracture results from a sudden increase in intraorbital pressure when the globe is being pushed posteriorly. 2) The fracture is the result of "buckling" forces which are transmitted to the orbital bones by transient deformity of the orbital rim.

Fractures of the inferior orbital wall are most common because of a combination of factors, namely the thinness of the maxillary roof, presence of the infraorbital canal, and the curvature of the floor. Immediately posterior to the rim, the orbital floor is concave and farther back it becomes convex. This configuration predisposes it to buckling and plays a major role in posttraumatic enophthalmos. Isolated fractures of the orbital roof are uncommonly seen in the absence of a fracture of the superior orbital rim. Isolated roof fractures are more common in the presence of a well-pneumatized orbital roof, and have a better prognosis when the orbital rim is spared.

Significant ocular injuries occur in 22-29 % of cases. A careful eye examination is critical. The profound swelling in the periocular region may somewhat limit the eye exam, as may the associated head injury. Globes with a history of cataract removal or other surgery are at much greater risk for perforation following trauma. Any history of previous visual problems or the use of contact lenses or glasses should be documented.

CLINICAL SIGNS AND SYMPTOMS

The main signs of orbital blowout fracture are

I. Diplopia is usually caused by restricted ocular movement, particularly in the upward gaze.

It is primary when in the central visual field. Under normal circumstances the eyes seldom deviate more than 20 degrees from the central axis, so diplopia in the the central visual field is very significant.

It is secondary when present only on extreme peripheral gaze. This may only be an issue when the patient looks out of the "corner of the eye".

Non-mechanical causes are less common and include injury to one or more of the extraocular muscles (EOM), damage to one of the nerves to an EOM, hematoma, and edema.

The Forced Duction Test is unreliable during the first week after injury because of non-mechanical causes of restriction very often give spurious results. For more on Diplopia see this article by Dr Jeff Mann.

6th nerve palsy => diplopia is greatest when looking to the affected side (abduction)

3rd nerve palsy => diplopia is greatest when looking up and to the opposite side (adduction)

4th nerve palsy => diplopia is greatest when looking down and to the opposite side (adduction)

III. Hypesthesia (or anesthesia) of the infraorbital nerve is common. It manifests as numbness of the gingiva and of the skin of the midface. If there is anesthesia of the gums--think posterior blowout fracture.

IMAGINING

Accurate characterization of all orbital fractures requires a CT scan. It is critical that coronal views be obtained. This may be problematic for patients with suspected cervical spine injuries, as coronal imaging requires hyperextension of the neck. In these patients, the axial images should be reformatted to provide coronal information. Sagittal reconstructions may also be helpful, particularly for those less experienced with orbital trauma. These provide a graphic representation of the superior incline of the orbital floor as one approaches the apex, something often not fully appreciated on the coronal images. Unlike the other facial fractures, evaluation of the soft-tissue windows is helpful with orbital injuries. The soft-tissue details help to show entrapment and/or displacement of the periorbital tissues including the extraocular muscles.

MEDICAL MANAGEMENT

Patients without significant enophthalmos (2 mm or more), a lack of marked hypo-ophthalmus, absence of an entrapped muscle or tissue, a fracture less than 50% of the floor, or a lack of diplopia can be treated conservatively. They will need to be followed closely to make sure nothing changes over the first few weeks/months.

The patient should be treated with oral or IV antibiotics (due to the disruption of the integrity of the orbit in communication with the maxillary sinus).

A short course of oral prednisone also may benefit the patient by reducing edema of the orbit and muscle. This also may allow for a more thorough assessment of the relative contribution to enophthalmos or entrapment from the fracture versus that from edema.

Discourage nose blowing to avoid creating or worsening orbital emphysema. Nasal decongestants can be used if not contraindicated.

SURGICAL MANAGMENT

Timing remains a controversial issue, though it is rarely ever considered emergent. Exceptions to this include situations when muscle is entrapped and possibly ischemic.

The classic example of this is the pediatric trap door injury, in which a defect opens in the floor and, because of the greenstick nature of the fracture, subsequently closes again.

Findings of entrapment include not just diplopia but often a vagal response, including nausea and syncope secondary to trapped parasympathetic nerve fibers that travel with the muscle.

So with the exception of entrapment, delaying the operation is feasible. This delay is beneficial in allowing the orbital swelling to resolve which improves exposure for the procedure. It takes 1-2 weeks for the swelling to resolve.

Prolonged delay may lead to suboptimal results. Up to 38% of patients who had surgery 2 months or longer after injury may be found to have diplopia compared to only 7% in those who had surgery within 2 months. It has been shown that 72% of patients who had operative repair after 6 month had enophthalmos compared to only 20% who had surgery within 2 weeks of injury.

Indications for surgery

Enophthalmos greater than 2 mm during the first 6 weeks

Significant hypoglobus

Diplopia, especially in the primary field of gaze that fails to resolve after 2 weeks

Large floor defect--defined by most as greater than 1 sq cm.

Significant advancements have been made in the evaluation and treatment of internal orbital fractures. Early operative intervention combined with wide exposure, meticulous reduction, and rigid fixation has significantly enhanced the treatment of internal orbital fractures.

BLINDNESS following blunt facial trauma is a rare but devastating injury caused by optic nerve compression. In 1982, Anderson reported on 7 cases of monocular blindness following frontal head trauma treated with megadose steroids or optic nerve decompression. Half had good response to steroids, while 1/4 had minor return of function after decompression. At Baylor, the following protocol is recommended:

Steroid therapy initially for all patients with optic nerve injury.

Decompression for all patients with subtotal or delayed vision loss and significant bony impingement or canalicular hematoma by CT.

Decompression for patient without CT findings that fail to respond to steroids within 12 hours

Decompression is not recommended for immediate blindness.

Dexamethasone Steroid Protocol ( from Anderson et al):

loading dose 0.75mg/kg

0.33 mg/kg q 6h x 24h

1 mg/kg q day x 1 - 2 days

If no response in 48 h, steroids stopped

If response, slow taper for 5 - 7 days, then quick taper off

COMPLICATIONS

Lid Retraction

This can be minimized with avoidance of the subciliary incision.

If retraction is appreciable in the early postoperative period, aggressive lower eyelid massage and forced eye closure exercises are instituted. This resolves the majority of cases.

Early operative intervention should be avoided unless significant corneal exposure and irritation are encountered. This is rarely seen with ectropion but is common in entropion, as the eyelashes are a source of constant irritation.

After 4 to 6 months of conservative therapy, unresponsive retractions may be better managed operatively. Regardless of initial incision, operative correction of lower lid retraction should be approached by means of a transconjunctival incision. Release of the middle lamella, the most common cause of significant postoperative retraction, should be followed by filling the defect with a graft of hard palate mucosa and a lateral canthoplasty.

Ocular Motility Deficits

Deficits in extraocular movements may be manifest as diplopia in the postoperative period. Although there is always concern regarding entrapment of these muscles, a normal forced duction test at the end of the procedure should effectively rule this out.

Frequently, periorbital swelling or muscular contusion and edema may be the underlying cause. Many patients with diplopia only at the extremes of gaze are not sufficiently bothered to seek intervention.

Diplopia is more problematic when in the primary field or in downgaze, which may interfere with walking.

When the deficit appears first following surgery, a computed tomographic scan should be performed to determine whether the implant is causing interference with the extraocular muscles. If the implant is well positioned, the patient should be followed conservatively along with the ophthalmologist. The need for future surgery and its timing is determined in large part by whether or not any improvement is noted and how distressing these symptoms are to the patient. The majority of these cases will resolve without intervention.

Enophthalmos is perhaps one of the most distressing and common problems seen in orbital fracture management.

The majority of cases are the result of persistent orbital volume enlargement secondary to nonanatomical restoration of the orbital cone.

On occasion, the implant may have been unintentionally placed in a horizontal orientation into the maxillary sinus.

The initial evaluation of postoperative enophthalmos should include a computed tomographic scan to determine implant location and to characterize intraorbital volume.

In some cases, the existing implant may be repositioned. This maybe difficult, however, as scarring of the periorbita can impede removal of the implant. In these cases, the implant should be elevated with the periorbita and a second implant placed. If this does not result in an appropriate globe position, additional volume should be added to the orbit. This can be done by placing a carved wedge of high-density porous polyethylene in a posterolateral location within the orbital cone. This allows the globe to project further without altering the vertical position. Just as with primary cases, the position of the globe should be overcorrected.

47 comments:

This whole series is giving me twitches--head/neck anatomy was always what I hated most about 1st-year studies! Fascinating, and a good treatment of the subject by you, but the flashbacks continue... ;)

I was googling around and came across your blog. I would like to run a couple questions by you and get an opinion if you don't mind. My 8 year old suffered an orbital blowout that instantly caused vision disturbances. They did a CT scan and it was determined that the muscle was trapped. We went the routes of opthamoligist, eye surgeon, and finally pediatric plastic surgeon. My questions are as follows.

1.) the surgery didn't take place until 2 weeks exactly after injury. The eye surgeon felt he was improving, and until I pressed that my son still couldn't look upright, and showed him via a different method than he was using, he was about to let us go. I have no idea why he couldn't see the visual differences. Does this sound normal?

2.)the surgery was considered a success in letting the trapped muscle go, but he still is having difficulty looking up...his eye tends to go up somewhat and then to the side. The surgeon who did the surgery says he may have to have muscle surgery 5 to 6 weeks down the road. Could this be from waiting too long? Could an earlier surgery help prevent a muscle problem, or could that have occured due to the injury?

I really feel like my son did not receive the care he should have, and I would like your opinion on whether or not you think this seems like a normal cause from injury or lack of good medical care. I think I would kick myself if I sat and waited for resolution, when I maybe shouldn't have.

I apologize if this is inappropriate, but I really feel like I should ask another professional and you had alot of information about this type of injury so maybe you have some experience with this...

Holly, thank you for reading, but I can not give you a "second opinion" for your son. If you aren't happy with the care he has or is receiving, then it is appropriate and your right to get a second opinion. When you do so, be sure to take all his records (written and film) to the surgeon who will be giving the second opinion.

I understand your inability to comment regarding my post. Thanks for reading, and taking the time to reply. I wondered if it was out of line to comment, but the most one can say is "no". So, no hard feelings.

Hi. I'm glad I found your article. I've had an orbital blowout fracture for a year or so now and I have a sunken in eye and flatter features on that side of my face. I can see fine and eye movement is fine although uncomfortable due to the obvious reasons. I'm still very afraid this will be permanent. Is there a more natural way of treating this without implants? And could my problems(flatter bloated looking features and sunken eye) be reversed 100%? Compared to the other eye, it looks sunken in about 2 mm or so.

Thank you for this very thoughtfully composed blog, which has provided a wide range of useful information to me.

I experienced an orbital blow-out fracture about six weeks ago, and underwent surgery two weeks ago to implant a porous titanium plate across my orbital floor. To remove scar tissue, bone fragments, and pooled blood from the injury, my surgeon identified that the 5th nerve would almost inevitably be nicked, and as a result I have a great degree of numbness on the left side of my face.

I understand that in most cases, this will go away within 6 months, but what I am most concerned about is the proper movement of the muscles around my eye, as it seems as though I have some lower eyelid retraction. I appreciate the information that you've been able to provide on lower eyelid massages and forced eyelid closures that may help improve this, but my question on this subject mostly pertain to timing.

In short, is it normal to have lower eyelid retraction in the weeks following an orbital blow-out repair, and if so, may this condition resolve on its own?

Laura, your question is not a simple one to answer, as it depends on the soft tissue injury and surgical approach. If it doesn't resolve or improve with the simple massage techniques within a few weeks be sure to see your surgeon and let them know.

Thank you for this site. It is very difficult to get information about what it is like to actually experience this surgery and what to expect afterwards. I had no idea healing would take so long, for example. I have a good surgeon, I just think he is busy and does so many of them that he didn't think to tell me.

I experienced a blowout fracture 2 months ago after slipping on ice. I had it repaired surgically with in 10 days of the accident so I'm 8 weeks into healing. I had two titanium plates inserted to hold the fractures together. It's doing better, but this is a slow process to be sure. I'm still not blinking fully in that eye and have a little bit of lower lid retraction which is improving. I'm also still experiencing some pain at the injury site but I think most of that is because of the orbital nerve. I will keep trying the massage even though it tends to make the area more sore.

Dr. Bates, thank you for sharing your expertise. This was very informative.

I sustained my blowout fracture exactly three weeks ago. I had my surgery 10 days ago. I had a full blow out, my surgeon was able to bring the bone back up and place a self absorbing plate.

I live in Houston and I feel like I have been blessed with a great Surgeon and care. When I went in for the follow up 5 days after the surgery. He said everything looks real good. I told him about my double vision and he said it would take time, that I had a lot of trauma and internal swelling.

I guess my questions to you are in regards to recovering time. What is an expected recovery time so that double vision goes away? does the eye take longer to heal than other parts of the body?

I have been wearing an eye patch. I can wear it on either eye. My bad eye is weaker, but I am able to see out of it pretty well.

Adrian, this is not really my area of expertise. I wrote this post to educate myself (a review if you will) as well as you and others. That said, if your double vision isn't improved within a few more months then be sure to return for follow up and make sure that it isn't an issue of weak muscles that needed to strenghten or swelling that needed to go. Best wishes to you.

caiden, we have the same situation going on. have you figured anything out yet? im very desperate to fix my face. i was hit by my x boyfriend jan. 3 and now im going on 7 months and i jus want this fixed ..........hope 2 here from u

Hey Doc i had a blow out frature they placed a absorbital plate for the floor the thing that is bothering me is my eye looks smaller then the other and its been about three weeks after surgery.i was wonrdering if my eye is sinking or would this just take time???

I just had a blowout fracture from an elbow to my eye. Everything seems fine (full motion, not out of place and full vision) except for not being able to blow my nose for an extended period of time. I actually filled my socket up with air before I knew I had broke my orbital. I know this sounds like a simple question, but is it ok to exercise (non contact, ie running) while it is healing, or do I risk getting sweat or blood into my eye socket or something?

Dave, it is best to ask your treating surgeon (as they know your fracture and how they treated it), but walking & stationary bike should be okay, as should yoga. Light weights to maintain muscle tone should also be okay. Running may be, but ask.

Hi, I was punched in the eye about 3 weeks ago and i feel a small fingertip size dip in the bone right below my eye. I've been feeling numbness down my cheek and on my upper lip. I understand i have a pinched nerve but I was wondering will this go away or are there other measures i should take to get this fixed. thanks so much for you time Doctor.

July 13 my son was playing basketball and the other boy head butted my son. So he gets home blow his nose and he said the air blew out his eye and it was bulged out and bruised shut. so we went to emergenty he gat a ct the emergency said the ct scan didnt show anything he reccomended the primary dr send him to a e.n.t.speacialist he said he is pretty sure it is a facial fracture. so here we are a month later his dr refused to reffer him and my son is having strange sensations that is leaving him in bed. He said he feels dizzy and nausea for three days he said it feel weird when he moves his head with his eyebrow. any suggestions

My son just had this surgery to release an entrapped muscle yesterday. I found your blog very useful in understanding all that was being done in this emergency surgery. We were very blessed to have received urgent, thorough care. The surgeon told us they were putting a dissolvable disc in - can you give me more information on this - it really fascinates me! Thanks!!

Again thank you doctor for providing the information above - it has been very useful. I had my surgery performed last week and had the silicon plate put in. I have noticed that my injured eye appears higher than my other eye. It is very noticeable particularly when I look up and the whites of my eye are revealed. Obviously my eye is still a little swollen from the operation but I was wondering if this is causing the misalignment and if it is likely that, as the swelling reduces, my injured eye will lower a little and fall back in line with my other eye?

Hey Doc, about 7 weeks ago my right eyeball was pressed extremely hard (constant pressure) for about 10 secs until it became unbearable and i had to stop it. My question is can pressing the eyeball extremely hard cause an Orbital floor fracture?

My eye was very sore and small the first 2 weeks after the incident. At about the 4th week my eye was slightly better in size and the soreness was gradually disappearing but was still present. I'm at the 7th week and my right eye still isn't the same size as it was originally and it gets fatigued easily.

Hi, I did a face plant on a wakeboard today had a CT scan done prelimanary report states: Fracture of the right medial orbital wall, depressed approx 3 mmNo significant herniation of intraorbital contents. Globe is intact. INtraorbital and periorbital emphysema. I did'nt evan know I hurt my self until I blew my nose and the skin around my eye inflated al most the size of a golf ball! With a fracture this size is surgery generally prescribed?

i have a hole an inch wide in the floor of mine.tissue and muscle have gone through..my eye has sunk back into the socket,and every puff of breath i take through my nose. my eye moves up in the socket,,,ive been left like this for two yrs..maxifacial keep making excuses tht my double vision will get worse if they fix it,plus my necks tht bad they say they cnt operate till i get my neck fixed...so im left with premanant double vision.and constant pain and pressure in my eye..plus its affected my upper neck as ive been twisting my head to try and see straight for two yrs..

Hi, thank you for a very informative blog. I recently undergone an orbital blowout surgery to repair a fracture of the orbital floor and medial wall of the left socket sustained from a blunt trauma to the eye. Initial CT scan showed orbital fat herniation but no muscle entrapment. This was 5 weeks ago. Prior to surgery, I experience double vision only on extreme upper left gaze. After the surgery, I now see double in up and down (less degree) gaze with noticable limited vertical movement of the left eye and misalignment between both eyes.

My surgeon wants to wait 3 more weeks to see if there's improvement before he orders another CT scan to determine if the MEDPOR implant was successful and rule out possible entrapment issue.

My questions are: Should I wait? Or should I consult with an Opthalmologist before then? Is it possible the surgery itself may have done additional / permanent damage to the inferior rectus muscle or the cranial nerve?

Anon (1/26/12): As per the disclaimer on this blog, I don't give individual medical advice here. As for your questions:Should I wait? -- If you and your doctor agree, it is the right thing to do. Surgical swelling could be the issue and it takes time to resolve.Or should I consult with an Opthalmologist before then? -- I would never tell someone not to seek a second opinion. If you are unsure, then do so.Is it possible the surgery itself may have done additional / permanent damage to the inferior rectus muscle or the cranial nerve? -- surgery is trauma and can cause damage (temporary, permanent). I hope your surgeon discussed the risk of complications from the surgery prior to the surgery.

A lot of good inforation here. I had a blowout injury one week ago and have my first ENT appointment in a few days. Mine is relativly small but a commuited fracture at the bottom of my orbital all the same. The PA, PCP, and radiologist have all said so far it is a "small" facture but definitly there with a "small" buldge of tissue coming down (seen on CT scan). I can move my eye fine in all directions and have normal vision. The main thing I am worried about is when the swelling goes down if my eye will sink. Personally any eye sinking I would opt for surgery. My question is, if my eye is indeed a low severity blowout what range of enophthalmos should I be expecting? Does it always happen to some extent with a blowout? Do I need to worry about bone fragments? Thanks Doc!

Jeff, I don't give individual medical advice via my blog. It is best ask your surgeon those questions when you have your consult. Most individuals with a low severity blowout will not have much enophthalmos. If you had a good MRI, then bony fragments should have been visible. Make sure you take your films with you to your consult. Best to you.

Thanks Doc, I realize you can not give individual medical advice, I am trying to gather all the infomation I can before I see my surgeon. I mean this not in my particular case but what have you seen in practice, what is the normal window that enophthalmos will become visable from your expeirence? From what im reading it can happen immediatly or can be seen after several weeks once everything settles. Also, do you think a blowout leaves you more suseptable in the future to further eye injuries? No more questions for me I swear! thanks doc!

Jeff, if you read through the comments above you will see this isn't really my area of expertise. I wrote this post as a review for myself and to help educate the public. Not sure what the normal window is, but would guess it's as with most injuries where swelling and fat loss take place: within a few weeks (if only swelling is an issue) and up to 6 months. Blowout, per say, shouldn't leave your eye more susceptible, but the healed bone is never quite as strong as before. So it is advisable to wear eye protection.

Hi, Wondering if you can tell me more about repair using medpor implants. Are there any long term issues with these when used in a child? Particularity interested in knowing how the implant exists with surrounding bone structure as it grows?

Hi. I would really appreciate some advice. I used an eye cream two weeks ago and when I woke up, I had severe headaches behind my eyes and both of my eyes have sunken deep into the socket tremendously. What could have caused this? Did the orbital fat behind my eyeball get damaged? Also, what surgical options do I have to fix the enophthalmos.

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